HIV Prevention and Trans People: What the Trans PULSE Project Can Tell Us

There is limited research available to help service providers understand transgender (or trans) people's risks for HIV. This can make it difficult for service providers to know how to provide culturally safe, respectful and appropriate services to trans people. The Trans PULSE Project, based in Ontario, has begun to address this gap by studying the health and HIV vulnerability of trans people in Ontario.

This article provides a brief introduction to terms and concepts that are important to understand in order to provide respectful and appropriate services to trans people. We also explore some of the key findings of the Trans PULSE Project and their implications for HIV prevention for trans people.

A Brief Introduction to Trans Identities

When many people think about gender, they think of two opposite categories (men and women) that never overlap or change. However, there are many people for whom this is not their experience of gender, and many of these people identify as trans. Trans people have existed throughout history.1 Unfortunately, the idea that gender is based in one's biology, or that there are only two categories of gender are fixed ideas in many people's minds. This is consistently reinforced through a lack of information about trans people and by policies that don't consider trans people.2

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The following is a list of general definitions about trans people. However, trans people are a diverse group and self-identifications may vary.

Trans people is an umbrella category for people who do not conform to society's gender norms of masculine and feminine.3 Within this category, some of the common terms people may use to identify include trans woman, trans man, genderqueer, two-spirit, or other identities. The following list is a general guide:

Trans women are people who were assigned a male sex at birth but identify as a (trans) girl or woman.3

Trans men are people who were assigned a female sex at birth but identify as a (trans) boy or man.3

Genderqueer people are people whose gender identity doesn't fit with the categories man or woman.

While many people identify as trans, some people who have transitioned to a new gender role identify themselves as men and women and do not necessarily use the term trans at all.

Aboriginal people may have different terms and understandings of gender than the ones listed above.4 For example, Two-spirit is an English translation of the anishinaabemowin words niizh manidoowag and refers to people who have both female and male spirits. It is used by some Aboriginal people who are gay, lesbian, bisexual, trans, or who have multiple gender identities.5 Other Aboriginal people may relate to other specific Aboriginal identities. A number of helpful resources about two-spirited people can be found on the 2-Spirited People of the 1st Nations website.

It's important to note that these are terms commonly used in North America. People from other parts of the world may have other terms and understandings of gender.

How Are Gender Identity and Sexual Orientation Different?

Gender identity is your experience of yourself as a woman, man, or another gender. Gender identity is different than sexual orientation, which is how you think of yourself in terms of your sexual and romantic attractions.3 For example, a trans man who is attracted to men (trans or non-trans) will likely identify as a gay or bisexual man. A trans woman who is attracted to women (trans or non-trans) will likely identify as bisexual or lesbian. Similar to non-trans people, trans people have a variety of sexual orientations including gay, straight, lesbian, bisexual and more. Put another way, sexual orientation refers to who you go to bed with, while gender identity refers to who you go to bed as.

Transitioning: What It Means

Some trans people choose to transition. This means that they make changes to their appearance or body (or both) to bring their expression of their gender in line with their felt gender. This may include socially transitioning, such as changing their name, clothing or hair style to be more masculine or feminine. It may include physically or medically transitioning by taking hormones, having surgeries or electrolysis to align their body with their identity.

Trans people make different choices about whether to transition or not. Some people may make all of these social and physical changes, some of them, or none of them. People's ability to transition can be significantly impacted by whether they can afford a new wardrobe, the cost of a name change, hormones or surgeries. In some provinces and territories, surgeries are covered by the provincial or territorial health insurance and in others they are not.

Do We Know How Many Trans People There Are in Canada?

There is no data on how many trans people live in Canada, as trans people are not explicitly included in the census or Statistics Canada surveys.6 However, using estimates from U.S.-based studies, the percentage of the population who identify as trans is between 0.3% and 0.5%.7,8 Applying this to the population of Canada,9 there may be between 97,652 and 146,087 trans people over the age of 14 living in Canada.

Do We Know How Many Trans People Are Living With Hiv in Canada?

There is also no data on how many trans people are living with HIV in Canada. National HIV testing data do not include trans people as a distinct category. For this reason it is very difficult to create a picture of how HIV affects trans people in Canada.

What Can HIV Research About Trans People From Outside of Canada Tell Us?

One meta-analysis looked at the rates of HIV in trans women in studies from 15 countries. In five of these studies, trans women from urban areas in five high-income countries had an HIV prevalence rate of 21.6%.10 However, some of these studies recruited from specific sites, such as HIV prevention programs and HIV testing sites and from among some sub-groups (for example, people who engage in sex work), which may have over-inflated the HIV prevalence rate. Actual national or international prevalence rates are not known. However, this prevalence rate does clearly indicate extremely high prevalence among some groups of trans women. Similar worldwide research on HIV rates among trans men are not available; however, results from five American studies estimated HIV rates for trans men to be between 0% and 3%.11

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